Provider Demographics
NPI:1053641803
Name:MIRAWORX OF OKC 1 LLC
Entity Type:Organization
Organization Name:MIRAWORX OF OKC 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:CUMMINS
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:918-286-7347
Mailing Address - Street 1:10400 VINEYARD BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3830
Mailing Address - Country:US
Mailing Address - Phone:405-230-1102
Mailing Address - Fax:
Practice Address - Street 1:10400 VINEYARD BLVD APT A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-3830
Practice Address - Country:US
Practice Address - Phone:405-230-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty